Critical Care in Norway

Share

Treatment of the critically ill is usually only infrequently debated
in public in Norway. However, in the last two years there have been a few ICU
cases that have generated a large amount of public interest in Norway. In these
cases, the issue usually stems from a conflict between ICU physicians and
relatives regarding ending life sustaining treatment. ICU physicians advise
ending treatment, but the relatives-often parents, refuse to accept this. In
the process, lawyers and media (newspapers and radio/television) become involved,
inflaming and complicating these issues.

The most well known incident was the “Kristinacase” named after
a 4-year critical ill girl. After a substantial rainfall in 2005, she was a
victim of a mudavalanche on her family’s home outside Bergen. Her mother died
as a result, but her father, and a brother and sister survived. She was found
submerged in mud after approximately one hour, but was initially resuscitated.
Unfortunately, she suffered severe hypoxic cerebral damage, and did not regain
consciousness. She also was ventilator dependent, but had blood supply to the
brain.

After internal discussion and utilising second opinions of
external experts, the medical team at Haukeland University Hospital advised
ending ICU treatment, but her father resisted. The local health authorities
supported the hospital’s decision. Still the disagreement continued, and her
case was taken to court in early 2006. It was the first time in Norwegian justice
history that a case was before the courts during continuing ICU treatment. The
court also supported the hospital’s decision, but the verdict was immediately appealed.

In February 2006, after 5 months of intensive care the hospital
turned off the ventilator against the father's will. Following this action,
expert groups reinvestigated the treatment given to her in hospital. The final
group, an international expert panel, reached their verdict this summer and the
hospital received full support of its actions. This case was extensively
documented and followed by various media, including being a topic in several
television debates. Politicians have also voiced their opinions, most strongly
supporting her father, stating that he (and parents in general) should be
responsible for making such a decision, not the doctors.

So the debate continues as to who should have the final word
when relatives and doctors do not agree about life sustaining treatments. Most
agree that communication is a key point, and that in most instances, good
communication over time will solve discrepancies and foster agreement, but as
we have experienced, this does not always happen.

After the Kristina-case, the medical community in Norway
acknowledged several general questions that this case raised:

What are the precise definitions of coma, chronic vegetative
status and related terms and are they agreed by all medical specialties?

What is the gold standard for objective testing regarding
impaired consciousness andcoma in
adults and children?

How should we utilise second opinions in a small country like
Norway?

What is the role of lawyers and courts in the decision-making
process?

What are the ethical issues regarding withdrawing or
withholding life-sustaining therapy?

The Norwegian Medical Association established a working group to
examine these issues in Autumn 2006. The Norwegian Directorate for Health and
Social Affairs also decided to create national guidelines regarding withdrawal
of life-sustaining therapy earlier this year after it became known that only
five Norwegian ICUs had written guidelines on how to proceed regarding ending
ICU treatment in the case of futility. Some politicians and one political party
wanted to implement a new law, stating that stopping ICU treatment was not
possible without consent from relatives. Such a law was voted down in the
Norwegian Parliament, but new guidelines are expected.

At present, the discussion is focused on second opinions and
whether a clinical ethical committee at another hospital should routinely
intervene in cases where there is disagreement between physicians and
relatives. However, as was illustrated this summer (2007), when there was a
dispute in another case, this can be challenging in practice. Ethical
committees are often difficult to summon on short notice, since in Norway they
have more often worked with cases in retrospect or "general" medical
ethical issues, not with ongoing cases.

These discussions have brought other issues to the forefront, namely
intensive care capacity in Norwegian hospitals. Overall, the number of ICU beds
is low in Norway with only 1 - 2% of the total hospital beds in university and
regional hospitals. In addition, many hospitals lack sufficient stepdown units,
making the pressure on ICU beds very high. This debate will hopefully lead to a
national discussion about the dimensions and aims for Norwegian intensive care
in general. But presently a national plan or guideline regarding intensive care
fails to exist. This is surprising given that one day of intensive care in ICU
in Norway costs around 4000 (euros), and is among the most expensive treatments
administered.

Norway, Critical Care, intensive care, ethics
Treatment of the critically ill is usually only infrequently debatedin public in Norway. However, in the last two years there have been a few ICUcases that

No comment

Highlighted Products

The technical and clinical reference standard for all B·R·A·H·M·S PCT assays.
All clinical cut-offs and algorithms were developed based on B·R·A·H·M·S PCT sensitive KRYPTOR.
Homogeneous immunoassay for the quantitative d

Get an complete overview of your POCT setup - from one dashboard
Your point-of-care-testing setup probably involves many different types of devices from various manufacturers. Radiometer's AQURE point-of-care management system can give you an overview...

The HAMILTON-C1 neo is a versatile neonatal ventilator that combines invasive and noninvasive modes with the additional options of nCPAP and high flow oxygen therapy. The integrated turbine allows it to be operated independently of a compressed air supply....

Medos customized tubing sets have been individually designed, so that all customer requirements, depending on application and need can be realized. Furthermore tubing sets can be refined by rheoparin or x.eed coating.

The HAMILTON-C3 ventilator is a modular high-end ventilation solution for all patient groups. Offering a number of unique features, the HAMILTON-C3 is one of the first ventilators featuring the “Ventilation Autopilot” INTELLiVENT-ASV®. The HAMILTON-C3’s...